BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GOVERNOR EDMUND G BROWN JR BOARD OF BARBERING AND COSMETOLOGY P.O Box 944226, Sacramento, CA 94244-2260 P (800) 952-5210 F (916) 575-7281 www.barbercosmo.ca.gov B arberCosmo i ~ro Ba·b~r"n &r ·~ met >QV Disclosure Statement Regarding Criminal Pleas/Convictions Failure to report a plea/conviction is considered falsification of the application and may result in the denial or revocation of licensure APPLICANT INFORMATION (incomplete forms will delay the processing of your application) Last Name First Name Telephone Number Middle Name E-mail Address (not required) DDDDDDDDDD DOD - DD - DODD Social Security Number or Individual Taxpayer Identification Number CONVICTION INFORMATION Date of Birth (must be at least 17 years old) DDDDDDDD Month Day Year (please complete one form for each plea or conviction, regardless of when the crime was committed) Arresting Agency Plea/Conviction Date Court Name and Location: Court Case/Docket Number Violation Code(s): Sentence: (Please describe any Punishment imposed by the court) Incarceration Date Release Date Probation/Parole Date Release Date Details of Crime: Please provide details of this crime, including a complete description of the facts and circumstances that led to your conviction You should include who participated in the crime, who the victim was; what losses were suffered; and when, where and how the crime occurred Attach additional pages as needed Explanation of Crime: Please explain why you committed this crime: Attach additional pages as needed Rehabilitation Efforts: What positive changes have you made in your life since this conviction? Please attach documentation to support the rehabilitation efforts Attach additional pages as needed I certify under penalty of perjury under the laws of the State of California that all statements furnished in connection with this form are true and accurate to the best of my knowledge Signature of Applicant Date Form C-01 (Revised September 2017)